Emergency repair and smoking predict recurrence in a large cohort of ventral hernia patients

Mapping the therapeutic landscape in emergency incisional hernia: a scoping review

PURPOSE

Incisional hernias (IH) represent common complications following abdominal surgeries, with emergency repair associated with increased morbidity and mortality. This scoping review aimed to map the existing literature on emergency incisional hernia repair, identify research gaps, and inform future guideline development.

METHODS

A comprehensive literature search was conducted in PubMed MEDLINE and SCOPUS for studies published between January 2000 and August 2024. Articles addressing any aspect of emergency incisional hernia repair in adults were included. Data extraction focused on study characteristics, patient demographics, surgical approaches, and outcomes.

RESULTS

Of 801 unique articles identified, 73 met the inclusion criteria. Most were cohort studies (73.97%), with only one randomized trial. The primary areas of interest were repair methods (47.95%), operative outcomes (31.51%), risk assessment (16.44%), and diagnosis (5.48%). Pooled analysis revealed a predominantly female (63%), elderly (mean age 62.3 years), and comorbid patient population. The most frequent study endpoints were readmission (18%), surgical site infection (12%), reoperation (8%), and mortality (4%). Significant heterogeneity was observed in defect characterization and surgical techniques.

CONCLUSION

This review highlights a paucity of randomized studies guiding emergency incisional hernia management. Key issues identified include inconsistent definitions of emergency presentation, limited data on hernia characteristics, and a lack of standardized outcome reporting. Future research should focus on developing a unified classification system for emergency incisional hernias, evaluating the role of imaging in decision-making, and conducting comparative studies on various treatment strategies across different clinical scenarios.

Primary and incisional hernias should be considered separately in clinical decisions and research: A nationwide register-based cohort study

BACKGROUND

Ventral hernias of umbilical, epigastric, and incisional types pose varied surgical challenges. Recent debates and research suggest that treatment strategies and outcomes may vary significantly based on hernia type and width. This study investigated whether differences in the risk of surgical outcomes among primary and incisional hernias are solely due to the hernia type. The primary outcome was reoperation for recurrence, and the secondary outcome was 90-day postoperative readmission.

METHODS

This study was based on prospectively collected data from the Danish Ventral Hernia Database linked with the Danish Civil Registration system and the National Patient Register. Data spanned from 2007 to 2022 and included patients with umbilical, epigastric, or incisional hernias. The 3 hernia types were analyzed for the risk of reoperation for recurrence, adjusted for sex, age, emergency repair, width, use of mesh, and Charlson comorbidity index.

RESULTS

We included 57,312 hernias: 34,147 umbilical, 9,433 epigastric, and 13,722 incisional hernias. Compared with patients with umbilical hernias, patients with epigastric hernias had a lower risk of reoperation (hazard ratio: 0.88, 95% confidence interval: 0.79-0.99) and those with incisional hernias had an increased risk (hazard ratio: 2.93, 95% confidence interval: 2.57-3.33). Postoperative 90-day readmission rates were also higher for patients with incisional hernias than for patients with umbilical and epigastric hernias.

CONCLUSION

Incisional hernias exhibited a higher risk of reoperation for recurrence and 90-day postoperative readmission, underscoring their unique nature in terms of both origin and clinical behavior. The findings suggest that primary and incisional hernias should be separate entities in medical practice and research.

The effect of clinically significant weight loss prior to open ventral hernia repair

PURPOSE

The study aim was to assess the impact of clinically significant weight loss (CSWL; ≥5% weight reduction) on postoperative complications following abdominal wall reconstruction with the component separation technique (CST).

METHODS

A retrospective review of patients who underwent open ventral hernia repair (VHR) with CST from November 2008 to January 2022 was performed. Cohorts were stratified by presence of CSWL from baseline weight at preoperative consultation.

RESULTS

Of 180 total patients, 40 (22.2%) achieved CSWL prior to VHR. Mean age was 59.6 ± 11.2 years. Patients in the CSWL cohort represented a higher average body mass index (BMI) (33.6 vs. 31.7 kg/m2, p = 0.076), and were obese more frequently (80.0% vs. 56.4%, p = 0.007). The CSWL cohort had a higher proportion of patients in Ventral Hernia Working Group (VHWG) classification II (82.5% vs. 63.6%) while the non-CSWL cohort had more VHWG classification III/IV (20.0% vs. 10.0%, p = 0.078). Mean follow-up duration was 6.1 ± 13.4 months. Complications, including 30- and 90-day surgical site occurrence (SSO), return to operating room, readmission, and hernia recurrence (CSWL: 5.0% vs. non-CWL 1.4%, p = 0.179), were comparable between cohorts. BMI was an independent predictor of any complication (OR 1.07, p = 0.044) and 90-day SSO (OR 1.10, p = 0.043).

CONCLUSION

Achievement of CSWL prior to open VHR utilizing CST results in similar post-reconstruction outcomes to patients who maintained a comparable BMI at baseline. Higher day-of-surgery BMI was more consequential to postoperative complications than percent weight loss.

Long-term outcomes of primary ventral hernia repair associated with rectus diastasis

Primary ventral hernia repair is a common global surgical procedure, entailing economic burdens and recurrence challenges. Rectus diastasis (RD) is considered a risk factor for midline defects and treatment is symptom-based. When primary ventral hernia and RD coexist, management still remains unclear. This study aims to analyze recurrence rates in patients after umbilical/epigastric hernia repair with untreated diastasis. Observational and retrospective cohort study of 74 patients assessing the recurrence rate of umbilical or epigastric hernias in patients operated with or without RD. Data were obtained from a tertiary hospital's patients between 2015 and 2017. Medium-term recurrences were analyzed after at least 3 year follow up. We compared demographic data, presence of RD (defined as rectus muscles separation exceeding 2 cm), type of repair and surgical complications. Data on 74 patients were collected. The mean age was 57.08 years, and the mean BMI was 31.27 kg/m2. Thirty-one included patients were females (42.9%). RD was documented in 67.1% of the sample. Mean follow-up was 4.23 (± 2.53) years. Postoperative complications were predominantly grade 1 according to the Clavien-Dindo classification, with a 17.14% surgical site infection rate. Female gender (p = 0.039), diabetes (0.016), and RD (0.049) showed statistically significant differences in predicting the risk of medium-term recurrence. Patients with untreated RD face a higher risk of medium-term recurrence following primary ventral hernia repair. Additionally, female gender and diabetes were found to be independent risk factors. Prospective studies are recommended to further assist surgeons in choosing the optimal surgical strategy for patients with umbilical hernia and associated RD.

Active smoking increases risk of wound complications in robotic enhanced-view totally extraperitoneal (eTEP) retro-rectus ventral hernia repairs

BACKGROUND

Tobacco smoking increases risk of complications after open hernia repair, however it is unknown whether this is true in minimally invasive hernia repair. We aim to determine whether there are differences in complication rates between smokers and non-smokers after robotic eTEP retrorectus repair.

METHODS

Our study included 102 patients who underwent robotic eTEP retrorectus repair of ventral hernias at a single institution from November 2019 to October 2022. Data collected included demographics, smoking status, operative details and outcomes. Patients were sorted into groups based on smoking status and outcomes were compared using ANOVA and chi-squared to test for significance.

RESULTS

Out of 102 patients, 18 were currently smoking, 38 were former smokers, 56 had ever smoked, 46 had never smoked and 84 were not currently smoking. Those who had ever smoked were more likely to endorse alcohol use compared to never smokers (60.7 vs 37%, p = 0.0169) and COPD was significantly more common in current smokers compared to not current smokers (p = 0.00025) and ever smokers compared to never smokers (p = 0.0037). Average follow up was 59.17 days and there was only one recurrence, which occurred in a never smoker. Initial analysis showed no difference in any complication. We excluded asymptomatic seromas that never required intervention due to clinical insignificance and repeat analysis showed current smokers had a significantly higher rate of surgical site occurrences (SSO) compared to patients not smoking at the time of their operation (p = 0.012). There was no difference between ever smokers and never smokers (p = 0.77). There remained no difference in any other complication.

CONCLUSION

Active smoking at the time of robotic eTEP increases the risk of clinically significant surgical site occurrences. This same increase is not seen in former smokers suggesting that smoking cessation should be encouraged before minimally invasive hernia repair.

Year-Over-Year Ventral Hernia Recurrence Rates and Risk Factors

Importance

Recurrence is one of the most challenging adverse events after ventral hernia repair as it impacts quality of life, utilization of resources, and subsequent need for re-repair. Rates of recurrence range from 30% to 80% after ventral hernia repair.

Objective

To determine the contemporary ventral hernia recurrence rate over time in patients with previous hernia repair and to determine risk factors associated with recurrence.

Design, Setting, and Participants

This retrospective, population-based study used the Abdominal Core Health Quality Collaborative registry to evaluate year-over-year recurrence rates in patients with prior ventral hernia repair between January 2012 and August 2022. Patients who underwent at least 1 prior ventral hernia repair were included and categorized into 2 groups based on mesh or no-mesh use. There were 43 960 eligible patients; after exclusion criteria (patients with concurrent inguinal hernias as the primary diagnosis, nonstandard hernia procedure categories, American Society of Anesthesiologists class unassigned, or no follow-up), 29 834 patients were analyzed in the mesh group and 5599 in the no-mesh group.

Main Outcomes and Measures

Ventral hernia recurrence rates. Risk factors analyzed include age, body mass index, sex, race, insurance type, medical comorbidities, American Society of Anesthesiologists class, smoking, indication for surgery, concomitant procedure, hernia procedure type, myofascial release, fascial closure, fixation type, number of prior repairs, hernia width, hernia length, mesh width, mesh length, operative approach, prior mesh placement, prior mesh infection, mesh location, mesh type, postoperative surgical site occurrence, postoperative surgical site infection, postoperative seroma, use of drains, and reoperation.

Results

Among 29 834 patients with mesh, the mean (SD) age was 57.17 (13.36) years, and 14 331 participants (48.0%) were female. Among 5599 patients without mesh, the mean (SD) age was 51.9 (15.31) years, and 2458 participants (43.9%) were female. When comparing year-over-year hernia recurrence rates in patients with and without prior mesh repair, respectively, the Kaplan Meier analysis showed a recurrence rate of 201 cumulative events with 13 872 at risk (2.8%) vs 104 cumulative events with 1707 at risk (4.0%) at 6 months; 411 cumulative events with 4732 at risk (8.0%) vs 184 cumulative events with 427 at risk (32.6%) at 1 year; 640 cumulative events with 1518 at risk (19.7%) vs 243 cumulative events with 146 at risk (52.4%) at 2 years; 731 cumulative events with 670 at risk (29.3%) vs 258 cumulative events with 73 at risk (61.4%) at 3 years; 777 cumulative events with 337 at risk (38.5%) vs 267 cumulative events with 29 at risk (71.2%) at 4 years; and 798 cumulative events with 171 at risk (44.9%) vs 269 cumulative events with 19 at risk (73.7%) at 5 years. Higher body mass index; immunosuppressants; incisional and parastomal hernias; a robotic approach; greater hernia width; use of a biologic or resorbable synthetic mesh; and complications, such as surgical site infections and reoperation, were associated with higher odds of hernia recurrence. Conversely, greater mesh width, myofascial release, and fascial closure had lower odds of recurrence. Hernia type was the most important variable associated with recurrence.

Conclusions and Relevance

In this study, the 5-year recurrence rate after ventral hernia repair was greater than 40% and 70% in patients with and without mesh, respectively. Rates of ventral hernia recurrence increased over time, underscoring the importance of close, long-term follow up in this population.

Causal relationship between cigarette smoking behaviors and the risk of hernias: a Mendelian randomization study

PURPOSE

As the global population continues to age, there is a noticeable yearly rise in the incidence of hernias. Simultaneously, smoking, a widespread addictive behavior and a significant contributor to mortality, has evolved into a pervasive public health concern. Existing literature has already established a connection between smoking and an increased risk of postoperative recurrence and postoperative infections following hernia surgery. However, there remains a dearth of research exploring the association between smoking and hernia morbidity. In this study, our objective is to systematically evaluate the causal relationship between cigarette smoking behaviors and hernia morbidity using a Mendelian randomization (MR) approach.

METHODS

Hernia-related data were sourced from the FinnGen Biobank database, while cigarette smoking behavior data were gathered from the GWAS and Sequencing Consortium of Alcohol and Nicotine Use. To assess the causal relationship, we employed five methods: the weighted median, the weighted mode the inverse variance weighted (IVW), MR-Egger, and the simple mode. Sensitivity analysis was conducted, incorporating Cochran's Q test, the MR-Egger intercept test, leave-one-out analysis, and funnel plot. The presentation of the causal relationship is expressed as an odds ratio (OR) along with their corresponding 95% confidence intervals (CI).

RESULTS

Employing the IVW method as the reference standard, we found that smoking intensity is associated with an increased risk of diaphragmatic hernia (OR = 1.21, 95% CI 1.00-1.46, P = 0.047). These consistent findings were further corroborated by the weighted median and weighted mode methods (OR = 1.26, 95% CI 1.03-1.54, P = 0.026; OR = 1.25, 95% CI 1.02-1.52, P = 0.045). Conversely, when applying the IVW method, we identified no statistically significant causal relationship between smoking age, smoking initiation status, smoking cessation status, and the incidence of hernia.

CONCLUSIONS

Our MR study has uncovered genetic evidence linking smoking intensity and the occurrence of diaphragmatic hernia. The risk of developing diaphragmatic hernia rises in tandem with the intensity of smoking. This emphasizes the crucial role of regularly advising patients to cease smoking in clinical settings.

Does smoking influence the clinical outcomes of robotic ventral hernia repair? A propensity score matching analysis study

The purpose of this study is to compare the clinical outcomes of robotic ventral hernia repair (RVHR) between smokers and non-smokers. Data for patients undergoing RVHR between 2012 and 2022 were collected. Patients were assigned to either smoking (+) or smoking (-) groups, according to their smoking status in the last 3 months prior to their procedure. Pre-, intra- and postoperative variables including surgical site occurrences (SSO) and infections (SSI), and hernia recurrence were analyzed after a propensity score matching analysis based on the patients' demographics and hernia's characteristics. Each group consisted of 143 patients matched according to their preoperative characteristics. There were no differences in terms of demographics and hernia characteristics. Intraoperative complications occurred at a comparable rate between both groups (p = 0.498). Comprehensive Complication Index® and all complication grades of the Clavien-Dindo classification were similar between both groups. Surgical site occurrences and infections did not differ either [smoking (+) vs. smoking (-): 7.6% vs 5.4%, p = 0.472; 5 vs. 0, p = 0.060, respectively). Rates of SSOs and SSIs that required any intervention (SSOPI) were similar in both groups [smoking (+): 3.1% vs. smoking (-): 0.8%, p = 0.370]. With a mean follow-up of 50 months for the cohort, recurrences rates were also comparable with 7 recorded in the smoking (-) versus 5 in the smoking (+) group (p = 0.215). Our study showed comparable rates of SSOs, SSIs, SSOPIs, and recurrence between smokers and non-smokers following RVHR. Future studies should compare the open, laparoscopic, and robotic approaches in smokers.

Assessing the effects of smoking status on outcomes of elective minimally invasive paraesophageal hernia repair

BACKGROUND

Patients are often advised on smoking cessation prior to elective surgical interventions, but the impact of active smoking on paraesophageal hernia repair (PEHR) outcomes is unclear. The objective of this cohort study was to evaluate the impact of active smoking on short-term outcomes following PEHR.

METHODS

Patients who underwent elective PEHR at an academic institution between 2011 and 2022 were retrospectively reviewed. The National Surgical Quality Improvement Program (NSQIP) database from 2010 to 2021 was queried for PEHR. Patient demographics, comorbidities, and 30-day post-operative data were collected and maintained in an IRB-approved database. Cohorts were stratified by active smoking status. Primary outcomes included rates of death or serious morbidity (DSM) and radiographically identified recurrence. Bivariate and multivariable regressions were performed, and p value < 0.05 was considered statistically significant.

RESULTS

538 patients underwent elective PEHR in the single-institution cohort, of whom 5.8% (n = 31) were smokers. 77.7% (n = 394) were female, median age was 67 [IQR 59, 74] years, and median follow-up was 25.3 [IQR 3.2, 53.6] months. Rates of DSM (non-smoker 4.5% vs smoker 6.5%, p = 0.62) and hernia recurrence (33.3% vs 48.4%, p = 0.09) did not differ significantly. On multivariable analysis, smoking status was not associated with any outcome (p > 0.2). On NSQIP analysis, 38,284 PEHRs were identified, of whom 8.6% (n = 3584) were smokers. Increased DSM was observed among smokers (non-smoker 5.1%, smoker 6.2%, p = 0.004). Smoking status was independently associated with increased risk of DSM (OR 1.36, p < 0.001), respiratory complications (OR 1.94, p < 0.001), 30-day readmission (OR 1.21, p = 0.01), and discharge to higher level of care (OR 1.59, p = 0.01). No difference was seen in 30-day mortality or wound complications.

CONCLUSION

Smoking status confers a small increased risk of short-term morbidity following elective PEHR without increased risk of mortality or hernia recurrence. While smoking cessation should be encouraged for all active smokers, minimally invasive PEHR in symptomatic patients should not be delayed on account of patient smoking status.